Newsletter guidance for healthcare providers on PSIRF and inquests

NHS England recently met with the Chief Coroner to explore how the Patient Safety Incident Response Framework (PSIRF) and the coronial process can work more effectively together. There is currently a critical challenge with the two processes because they serve fundamentally different purposes.

PSIRF supports organisational learning and deliberately avoids apportioning blame or identifying cause of death, whilst coroners must answer four statutory questions, including how someone came by their death. 

A newsletter has been published following the meeting, confirming that coroners should no longer expect or require Root Cause Analysis (RCA) reports in place of PSIRF learning responses, as this is no longer the nationally endorsed approach. Evidence gathering for PSIRF and inquests must remain distinct, with causation potentially needing to be established through other means.

Understanding PSIRF's purpose and scope

PSIRF was introduced to the NHS in England in August 2022 following more than four years of development, testing and evaluation, and became mandatory within the NHS Standard Contract from April 2024. It replaced the Serious Incident Framework (SIF), and sought to address weaknesses in incident response highlighted by patients and families, health professionals, regulators, academics and Parliament. PSIRF is mandatory for all health services contracted under the NHS Standard Contract, including services delivered by NHS acute, ambulance, mental health, community, maternity and specialised providers. It also applied to NHS-funded care delivered by independent healthcare providers.

PSIRF moves away from a single, linear method (RCA) towards a systems-based approach, widely regarded across safety-critical industries as best practice for learning and improvement. RCA often oversimplified complex events and failed to identify interacting systemic factors, leading to narrow and ineffective actions. In contrast, PSIRF seeks to enable proportionate responses using varied evidence-based methods to generate learning, fostering openness and a culture of continuous improvement. 

The implementation of PSIRF aims to strengthen the ability to learn from incidents, but it has also introduced new challenges in how healthcare providers interact with coronial processes.

The fundamental difference between PSIRF and coronial requirements

PSIRF is designed to support organisational learning and improvement, and deliberately excludes activities such as apportioning blame, determining liability, assessing preventability, or identifying cause of death. PSIRF learning responses take a 'window on the system' approach, exploring how work happens in everyday practice rather than focusing solely on a single incident.

In contrast, coroners are legally required to answer four statutory questions, including how someone came by their death, which often involves establishing causation and examining the circumstances surrounding a specific death. This difference means PSIRF outputs, which focus on systemic insights rather than direct causation, may be less directly useful for coronial purposes.

Some coroners, accustomed to Serious Incident investigation reports that provided clear chronologies and RCA, now find that PSIRF outputs, whilst richer in systemic insight, are lacking the causation detail they expect.

The agreed position: Distinct evidence gathering

In their joint newsletter, both NHS England and the Chief Coroner agreed that evidence gathering for a PSIRF learning response and for an inquest must remain distinct so that each achieves its intended aim. This means coroners may need causation to be established through other means and should no longer expect or require an RCA in place of a learning response, as this is no longer the nationally endorsed approach.

PSIRF outputs, including the rationale for the chosen response and any improvement actions, can provide valuable context about wider circumstances and system changes. Coroners may continue to use learning response outputs as supplementary information when available; however, these should not be relied upon as the primary or sole evidence for an inquest.

Practical takeaways for NHS Trusts and other healthcare providers utilising PSIRF

The discussion between the Chief Coroner and NHS England focused on a shared goal: ensuring coroners receive the information they need for inquests while preserving PSIRF’s core principle of fostering a learning culture within healthcare. Key takeaways for NHS Trusts and other healthcare providers utilising PSIRF are: 

1. Plan for separate causation evidence for the inquest

The PSIRF learning response will not address causation and so for the purposes of the inquest causation will need to be established through other evidence. Providers should consider what additional investigation or evidence may be required to satisfy coronial requirements, separate from the PSIRF learning response process. This may include the post mortem, an internal clinical opinion on causation or, in some cases, independent expert evidence. 

2. Establish early coordination between legal and patient safety teams

Trust or healthcare provider legal teams should liaise with patient safety teams at an early stage to understand what PSIRF learning response is being undertaken and to identify and address any gaps in the evidence required for the inquest. This early collaboration is essential given that PSIRF learning responses and inquest evidence gathering are distinct and a PSIRF learning response may not satisfy the evidential requirements for an inquest.

3. Use PSIRF outputs strategically

Whilst learning response outputs should not be relied upon as primary inquest evidence, they can provide valuable supplementary information about wider circumstances and system improvements. This may be particularly important for the Coroner when considering their duty under Regulation 28 (Prevention of Future Deaths Reports). Consider how to present this contextual information effectively to coroners alongside the specific causation evidence they require.

4. Maintain the integrity of both processes

By working collaboratively, both parties can uphold the integrity of the coronial process whilst fostering a culture of learning and improvement across healthcare. Resist pressure to compromise either the learning-focused nature of PSIRF or the evidential requirements of inquests by maintaining clear separation between the two processes.

5. Challenge coroners requesting RCA reports

Where a coroner is insisting on an RCA or Serious Incident-type response following a death, the joint newsletter demonstrates that this is no longer the nationally endorsed approach and a coroner should not expect or require such a report for an inquest. Trusts and other healthcare providers may wish to share the Chief Coroner and NHS England newsletter with coroners who continue to make such requests.

To discuss the PSIRF and coronial duties in more detail, please speak to our specialist inquests team.